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.IDB ADDRESS: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Di m 3 of the Business and ProtessIons Code and my license is in full force and effect License'if zuy j��I _Expiration Date -11311, _ Data_..C. Con`vactw�._--- � r_4�i'�_I-tt �.vL. OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason(Section 7031 5.Business and Professions Code. Any city or county which requires a permit 10 construct, her.Improve_demolish_or repair any strucure,prior to m issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 Of the Business and Professions Code)or that he Is exempt herth efrom and me basia for the alleged exemption Any violation of Section 7031.5 by any applicant for a permit subjects to a civil penalty of not more an five hundred dollars(5me applicant500))' ❑I,as owner of the property,or my employees with wages as their soie compensation w,11 do the work,and the structure is not intended or offered for sale(Section 7044.Business and Professions CodeThe CORtractdYs License Law does not apply to an owner Of property ono builds or improves thereon,and who does such work himself or through his awn employees,provided that such improvements are not intended or offered for sale If however,the building or Improvement u sold within one year of ccmWetgn,the owner-budder wig have the burden of provmg that he did not build or improve for the purpose of sale} ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the prgect(Section 7044,Business aro Professions Code(BAPC): The Contractor's License Law does not apply to an owner of property who builds or Improves hereon. iand who constructs for such projects with a contneclor(s)licensed pursuant to the Contisctor's License Law.) 111 am exempt under Section _ BdPC for this reason Data: owner— WORKERS' vineWORKERS'COMPENSATION DECLARATION I hereby affirm that t have a certificate of consent to self-msure or a certificate of Workers Compensation Insurance,or a certdled copy thereof(Section 3800 Labor Code) Expiration Date_____ ___ Company O Certified copy is hereby furnished ❑Certified Copy is filed with the Envirormental Health Department CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE I (Thls section need not be comOleted If the oermt is for one hundred dollars I S 1001 or less, I certify that In the performance of the work for which this peri(Is issued,I shall not employ become subject to the workers'Compensation taws of California. F Y any Parson in any manner so as to Date: Applicant —_ NOTICE TO APPLICANT If,ager making this Certificate of Exemption,you should become sub provisions of the Labor Code,you must forthwith coin with such subject to the wodcan'Compensation WY previsions or mice permit shall tie tleernetl revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the Performance of the work for which this Penn is issued(Section 3097, Civil Code). Lender's Name Lender's Address DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION O I hereby certify that no excavation five(5)or more feet in depth into which a person is required to descend,will be made in connection with work authorized by the Permit and that no budding structure.scaffolding,falseirork.or demolition or dismantling thereof.wits be more than thirty-six(36)feet high.(Chapter 3.2.Group 2 Article 2,Section 341 Title 8,California Administrative Code). 0 As owner-builder.I will not employ anyone to do work which would require a permit from the Division of trbuatriel Safety,as noted above,unless such person has a Permit to do such work from the division O DhMfon of Industrial Safety Permit s I coryfy that I have mad this application and state that the above information is Corea I agree to comply with all city and county Ordinances and state Laws(elating to well construction and or sewage system construction,and hereby authorize representatives Of this county to enter upon the above-mentioned property for inspection purposes Dab_ —__- --- -- Applicant E/D4S02-0gI 626119 LICENSED CONTRACTORS DECLARATION Y